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Health Care as a Complex Adaptive System

Health Care as a Complex Adaptive System

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Published by: Chowdhury Golam Kibria on Jan 05, 2011
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Health Care as a Complex Adaptive System: Implications for Design and Management
Management of complex adaptive systems requires leadership rather than power, incentives and inhibitions rather than command and control.
 For several years, the National Academies has been engaged in a systemic study of thequality and cost of health care in the United States (IOM, 2000, 2001; National Academy ofEngineering and Institute of Medicine, 2005). Clearly, substantial improvements in thedelivery of health care are needed and, many have argued, achievable, via value-basedcompetition (e.g., Porter and Teisberg, 2006). Of course, it should be kept in mind that ourhealth care system did not get the way it is overnight (Stevens et al., 2006).Many studies by the National Academies and others have concluded that a major problemwith the health care system is that it is not really a system. In this article, I elaborate on thedifferences between traditional systems and complex adaptive systems (like health care) andthe implications of those differences for system design and management.
Complex Adaptive Systems
 Many people think of systems in terms of exemplars, ranging from vehicles (e.g., airplanes) toprocess plants (e.g., utilities) to infrastructure (e.g., airports) to enterprises (e.g., Wal-Mart). Inaddition, they often think of improving a system by decomposing the overall systemperformance and management into component elements (e.g., propulsion, suspension,electronics) and subsequently recomposing it by integrating the designed solution for eachelement into an overall system design.This approach of hierarchical decomposition (Rouse, 2003) has worked well for designingautomobiles, highways, laptops, cell phones, and retail systems that enable us to buyproducts from anywhere in the world at attractive prices. The success of traditional systemsdepends on being able to decompose and recompose the elements of the system and, most
 
decomposition. For example, decomposition may result in the loss of important informationabout interactions among the phenomena of interest. Another fundamental problem for verycomplex systems like health care is that no one is “in charge,” no one has the authority orresources to design the system. Complex adaptive systems tend to have these design andmanagement limitations.Complex adaptive systems can be defined in terms of the following characteristics (Rouse,2000):
They are
nonlinear and dynamic 
and do not inherently reach fixed-equilibrium points.As a result, system behaviors may appear to be random or chaotic.
They are composed of
independent agents 
whose behavior is based on physical,psychological, or social rules rather than the demands of system dynamics.
Because agents’ needs or desires, reflected in their rules, are not homogeneous,their
goals and behaviors are likely to conflict 
. In response to these conflicts orcompetitions, agents tend to adapt to each other’s behaviors.
Agents are
intelligent 
. As they experiment and gain experience, agents learn andchange their behaviors accordingly. Thus overall system behavior inherently changesover time.
Adaptation and learning tend to result in
self-organization 
. Behavior patterns emergerather than being designed into the system. The nature of emergent behaviors mayrange from valuable innovations to unfortunate accidents.
There is
no single point(s) of control 
. System behaviors are often unpredictable anduncontrollable, and no one is “in charge.” Consequently, the behaviors of complexadaptive systems can usually be more easily influenced than controlled.Before elaborating on these characteristics in the context of health care, it is useful to reflecton an overall implication for systems with these characteristics. One cannot command orforce such systems to comply with behavioral and performance dictates using anyconventional means. Agents in complex adaptive systems are sufficiently intelligent to gamethe system, find “workarounds,” and creatively identify ways to serve their own interests.
TABLE 1 Stakeholders and Interests in Health Care
 
Stakeholder
 
RiskManagement
 
Prevention
 
Detection
 
Treatment
 Public e.g., buyinsurancee.g., stopsmokinge.g., getscreenedDelivery System Clinicians
a
Clinicians andproviders
b
 Government Medicare,Medicard,CongressNIH, GovernmentCDC,DoD, et al.NIH, GovernmentCDC,DoD, et al.NIH, GovernmentCDC,0DoD, et al.Non-Profits American CancerSociety,American HeartAssociation, etal.American CancerSociety,American HeartAssociation, etal.American CancerSociety,American HeartAssociation, etal.Academia Business schoolsBasic sciencedisciplinesTechnology andmedical schoolsMedical schoolsBusiness Employers,insuranceGuidant,Medtronic, et al.Lilly, Merck,Pfizer, et al.
 
companies,HMOs
a
The category of clinicians includes physicians, nurses, and other health care professionals.
b
The category of providers includes hospitals, clinics, nursing homes, and many other types oftesting and treatment facilities.
The Health Care Game
 Consider the large number of players, or “agents,” involved in the health care game (Table 1).It is reasonable to assume that each type of agent attempts to both serve its own interestsand provide quality products and services to its customers. However, there are conflictinginterests among stakeholders, just as there are different definitions of quality. Thus, evenassuming that all agents are well intentioned, the value provided by the health care system ismuch lower than it might be, in the sense that health outcomes may be compromised and/orthe costs of delivering these outcomes may be excessive.Working with the American Cancer Society, we studied the value chain associated withdisease detection (Rouse, 2000). Many people naively believe that new detection technologyis the key to successful detection. However, unless we address consumer awareness,consumer education, physician education, and consumer advocacy, to name a few of theother components of the value chain, patients may not experience the benefits of newdetection technologies. In general, enormous investments in medical research will notsubstantially improve health care outcomes unless they are introduced with an understandingof the overall system.In this context, it is useful to look more closely at the two cells in Table 1 that includephysicians. One aspect of the overall health care value chain is the process of education andcertification that provides trained, licensed physicians. Physician education and training arecurrently being reexamined to identify future physician competencies and determine the bestway to provide them. Some of the many stakeholders in this process are listed below:
Accreditation Council for Continuing Medical Education
Accreditation Council for Graduate Medical Education
American Academy of Family Physicians
American Board of Medical Specialties
American Medical Association
American Osteopathic Association (AOA)
AOA Council on Postdoctoral Training
Council of Medical Specialty Societies
Federation of State Medical Boards
Joint Commission on Accreditation of Healthcare Organizations
Liaison Committee on Medical EducationThis list is representative, but not exhaustive. In addition, many functions of theseorganizations are state specific, so there might be 50 instances of these academies, boards,committees, and councils.Even from this brief description, it is apparent that the system of health care delivery involveswhat we might call networks of networks or systems of systems that involve an enormousnumber of independent stakeholders and interests, layered by organization, specialty, state,and so on. If this system is approached in the traditional way, decomposing the elements ofthe system, designing how each element should function, and recomposing the overallsystem would be overwhelming. Thus we must address health care in a different way andfrom a different point of view—as a complex adaptive system.

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